Healthcare Provider Details

I. General information

NPI: 1417043886
Provider Name (Legal Business Name): WILLIAM D. KIRK M.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W HIGH ST
LEBANON KY
40033-1428
US

IV. Provider business mailing address

312 W HIGH ST
LEBANON KY
40033-1428
US

V. Phone/Fax

Practice location:
  • Phone: 270-692-9559
  • Fax: 270-692-9236
Mailing address:
  • Phone: 270-692-9559
  • Fax: 270-692-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26011
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26011
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26011
License Number StateKY

VIII. Authorized Official

Name: DR. WILLIAM DEADRICK KIRK
Title or Position: OWNER
Credential: M.D.
Phone: 270-692-9559